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To access the supporting information, hold down Ctrl and left click the icon COPD- Specialist Management of acute exacerbation Key Background 1 Backing Information Primary Care COPD – acute exacerbation specialist care Information resources for patients and carers 3 Secondary Care Referral Template 2 Admission advice to inform effective discharge 4 Consider differential diagnosis 5 Clinical assessment 6 7 Complete the venous thromboembolism (VTE) risk assessment 8 Further investigations Patient not in respiratory failure Patient in respiratory failure 9 10 Initial treatment 11 Consider ventilatory support 13 Bronchodilators Oxygen therapy 14 Corticosteroid therapy 16 15 Monitor progress 20 23 Consider ventilatory support 12 Planning for discharge 24 Antibiotic and other available treatments 17 Progress satisfactory 18 Monitor progress 21 Pulmonary rehabilitation 25 Informing effective discharge 26 Follow-up care 28 30 Refer back to primary care 27 Informing effective discharge Follow-up care 29 Long- term follow-up 31 Planning for discharge 32 Refer back to primary care Go to stable COPD pathway Long- term followup 33 Go to Stable COPD pathway Approval Date: March 2011 Review Date: March 2013 Page 1 of 16 Progress not satisfactory 19 Consider palliative 22 care 1 Background information Scope: early detection, diagnosis, assessment and management of chronic obstructive pulmonary disease (COPD) in adults interventions include: o inhaled and oral therapies o oxygen therapy o pulmonary rehabilitation o surgical interventions o management of psychological sequelae o health promotion and preventive measures management of complications of COPD including: o respiratory failure o cor pulmonale o abnormal body mass index (BMI) covers criteria for specialist referral covers principles of palliative care in COPD Out of scope: smoking cessation palliative care Definition: COPD is characterised by airflow obstruction: o forced expiratory volume in 1 second (FEV1) less than 80% predicted and FEV1/forced vital capacity (FVC) ratio less than 0.7 airflow obstruction is due to a combination of airway and parenchymal damage COPD is an umbrella term that includes: o emphysema o chronic bronchitis o chronic airflow limitation o the definition may include some cases of chronic asthma Incidence and prevalence: an estimated 3 million people are effected by COPD in the UK: o approximately 2 million of these remain undiagnosed rate of COPD in the population is estimated to be between 2-4% incidence is difficult to determine as disease develops insidiously prevalence rates are increasing in women but have reached a plateau in men Prognosis: COPD accounts for approximately 30,000 deaths each year in the UK (more than 90% of these occur in those over age 65 years) mortality from COPD in England shows a strong urban rural gradient Risk factors: smoking occupational exposure increasing age deprived communities Click here to go back to the pathway 2 Information resources for patients and carers Patients and carers can access this pathway through NHS Choices at http://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease/pages/introduction.aspx The following resources have been produced by organisations certified by The Information Standard: 'COPD' (PDF) from BMJ at http://www.group.bmj.com Date agreed: February 2011 Review Date: February 2013 Page 2 of 16 'Chronic Obstructive Pulmonary Disease (COPD)' (URL) from BUPA at http://www.bupa.co.uk 'Chronic obstructive pulmonary disease' (URL) from Datapharm at http://www.medguides.medicines.org.uk 'Understanding NICE guidance: Chronic obstructive pulmonary disease' (PDF) from national Institute for Health and Clinical Excellence (NICE) at http://www.nice.org.uk 'Chronic Obstructive Pulmonary Disease' (URL) from Patient UK at http://www.patient.co.uk The Carers Resource at http://www.carersresource.org Information for carers and people with disabilities is available at: 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk Explanations of clinical laboratory tests used in diagnosis and treatment are available at ‘Understanding Your Tests’ (URL) from Lab Tests Online-UK at http://www.labtestsonline.org.uk. Click here to go back to the pathway 3 COPD - acute exacerbation specialist care definition: o sustained worsening of the patient's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication diagnosis of exacerbation is made clinically – it does not depend on the results of investigations, but investigations may at times assist in ensuring appropriate treatment is given worsening of previously stable condition presenting features of acute exacerbations of chronic obstructive pulmonary disease (COPD): o increased wheezing (rhonchi) o increased dyspnoea o increased sputum volume o increased sputum purulence o cough o chest tightness o fluid retention o respiratory failure Click here to go back to the pathway 4 Admission advice to inform effective discharge Maintaining high quality medical records is a fundamental and crucial component of good clinical practice. Omissions, errors, and illegible records undermine the quality and safety of clinical care and expose doctors and health care providers units to increased risk of clinical incidents, complaints, and litigation. [Bridgelal Ram] The following is designed to serve as a concise reminder for clinicians to ensure patient discharge notes are accurate, and to facilitate effective discharge. HIU Discharge Summary The following should be recorded and updated throughout the patient's hospital stay: GP details: record the details of the patient’s usual GP. Patient details: record the patient details, including NHS number and home address. Admission details: record the method of admission (e.g. emergency, elective, transfer, maternity), hospital site, responsible Trust, and date of admission. Discharge details: record date of discharge, method (e.g. on clinical advice, self-discharge), discharge destination, discharging consultant, and discharging specialty/department. Clinical information: record diagnosis at discharge, operations and procedures performed during admission, relevant legal information (e.g. Mental Capacity Act 2005), allergies, risks and Date agreed: February 2011 Review Date: February 2013 Page 3 of 16 warnings, clinical narrative, outstanding investigations, measures of physical ability and cognitive function, medication changes, and discharge medications. Advice, recommendations, and future plan: record actions required by hospital and/or GP, actions requested/planned/agreed with community, and specialist services. Patient’s concerns, expectations, and wishes Information given to patient and/or authorised representative Results awaited Person completing the summary: record doctor’s name and GMC number, grade, signature, date of completion, and bleep number. High quality discharge notes ensure proper documentation of patient care and treatment plans, minimise variability and errors during discharge, and assure continuity of care and communication between care providers. The Health Informatics Unit of the Royal College of Physicians (RCP), London, UK, working on behalf of the Academy of Medical Royal Colleges (AMRC) developed a discharge medical record keeping standard. [RCP 1, RCP 2] The standard was approved by the AMRC in 2008. The standard is designed to encourage formal discharge planning at the point of admission for all in-patients and effective transfer of care tailored to the patient’s health needs and local care provider context. Click here to go back to the pathway 5 Consider differential diagnoses differential diagnoses: o pneumonia o pneumothorax o left ventricular failure o pulmonary embolism o lung cancer o upper airways obstruction Click here to go back to the pathway 6 Clinical assessment History: particular note should be made of: o the known exercise tolerance (which should include a careful record both of how independent the patient is under normal circumstances and during the exacerbation) o current treatments, especially the use of nebulisers and long-term oxygen therapy (LTOT) o time course of the current exacerbation o the patient's social circumstances and quality of life – especially whether living alone, alone with support, with family and an indication of the suitability of the accommodation o number of previous admissions in the past 5 years, including admissions to the intensive care unit (ICU) o smoking history Examination: signs suggesting a significant deterioration include: o infection (pyrexia, frankly purulent sputum) o severe airways obstruction (audible wheeze [rhonchus], tachypnoea, use of accessory muscles) o peripheral oedema o cyanosis o confusion Click here to go back to the pathway Date agreed: February 2011 Review Date: February 2013 Page 4 of 16 7 Further investigations For all patients referred to hospital: chest X-ray arterial blood gas tensions (record inspired oxygen concentration (FiO2), e.g. if breathing air FiO2 = 0.21 full blood count (FBC) and urea and electrolytes theophylline level in patients on theophylline at admission electrocardiogram (ECG) (to exclude co-morbidities) sputum microscopy and culture if purulent if pyrexial (or pneumonia is suspected), blood cultures are recommended Click here to go back to the pathway 8 Complete the venous thromboembolism (VTE) risk assessment All patients should undergo venous thromboembolism (VTE) risk assessment as per National Institute for Health and Clinical Excellence (NICE) guidance: upon admission for a second time, within 24 hours of initial assessment regularly thereafter for the duration of the inpatient stay, and, in some cases, following discharge whenever the clinical situation changes Click here to go back to the pathway 9 Patient not in respiratory failure Respiratory failure = failure to maintain adequate gas exchange – characterised by abnormalities of arterial blood gas tensions: partial pressure of oxygen in arterial blood (PaO2) less than 8.0kPa with or without PaCO2 more than 6.7kPa Click here to go back to the pathway 10 Patient in respiratory failure Respiratory failure = failure to maintain adequate gas exchange – characterised by abnormalities of arterial blood gas tensions: partial pressure of oxygen in arterial blood (PaO2) less than 8.0kPa with or without PaCO2 more than 6-0kPa Click here to go back to the pathway 11 Initial treatment bronchodilators corticosteroid therapy Oxygen therapy Antibiotic respiratory stimulants: o use doxapram only when non-invasive ventilation is unavailable/considered inappropriate pulmonary emboli are more common than is usually recognised in severe COPD but the benefit of prophylactic anticoagulation treatment has not been evaluated Click here to go back to the pathway Date agreed: February 2011 Review Date: February 2013 Page 5 of 16 12 Consider ventilatory support Ventilatory support: either non-invasive intermittent positive pressure ventilation (NIPPV) or invasive intermittent positive pressure ventilation (IPPV) via an endotracheal tube consider in patient with: o pH of less than 7.35; and/or o rising partial pressure of carbon dioxide in arterial blood (PaCO2) which fails to respond to supportive treatment and controlled oxygen therapy the decision to institute or to withhold ventilatory support must be made by a senior person with as much information as possible about the patient's pre morbid state Non-invasive ventilation (NIV): treatment of choice for persistent hypercapnic ventilatory failure despite optimal medical therapy deliver in a dedicated setting with experienced staff trained in its application when starting NIV, agree clear plan covering: o what to do in the event of deterioration o ceilings of therapy consider NIV for patients who are slow to wean from invasive ventilation refer to a specialist centre for consideration of long-term NIV Local Information Non-Invasive Ventilation is currently only available on ITU at Morriston. A Ward-based service is under consideration. Invasive ventilation: factors to encourage use of IPPV: o a demonstrable remedial reason for current decline, e.g. radiographic evidence of pneumonia or drug over-dosage o the first episode of respiratory failure o an acceptable quality of life or habitual level of activity Factors likely to discourage use of IPPV: previously documented severe COPD that has been fully assessed and found to be unresponsive to relevant therapy a poor quality of life, e.g.. being housebound, in spite of maximal appropriate therapy severe co-morbidities, e.g.. pulmonary oedema or neoplasia NB: Neither age alone nor the PaCO2 are a good guide to the outcome of assisted ventilation in hypercapnic respiratory failure due to COPD (a pH of more than 7.35 is a better predictor of survival during the acute episode). Click here to go back to the pathway 13 Consider ventilatory support Ventilatory support: either non-invasive intermittent positive pressure ventilation (NIPPV) or invasive intermittent positive pressure ventilation (IPPV) via an endotracheal tube consider in patient with: o pH of less than 7.35; and/or o rising partial pressure of carbon dioxide in arterial blood (PaCO2) which fails to respond to supportive treatment and controlled oxygen therapy the decision to institute or to withhold ventilatory support must be made by a senior person with as much information as possible about the patient's pre morbid state Non-invasive ventilation (NIV): treatment of choice for persistent hypercapnic ventilatory failure despite optimal medical therapy deliver in a dedicated setting with experienced staff trained in its application Date agreed: February 2011 Review Date: February 2013 Page 6 of 16 when starting NIV, agree clear plan covering: o what to do in the event of deterioration o ceilings of therapy consider NIV for patients who are slow to wean from invasive ventilation: consider respiratory stimulant if NIV is not available Local Information Non-Invasive Ventilation is currently only available on ITU at Morriston. A Ward-based service is under consideration. Invasive ventilation: factors to encourage use of IPPV: o a demonstrable remedial reason for current decline, e.g. radiographic evidence of pneumonia or drug over-dosage o the first episode of respiratory failure o an acceptable quality of life or habitual level of activity Factors likely to discourage use of IPPV: previously documented severe COPD that has been fully assessed and found to be unresponsive to relevant therapy a poor quality of life, e.g.. being housebound, in spite of maximal appropriate therapy severe co-morbidities, e.g.. pulmonary oedema or neoplasia NB: Neither age alone nor the PaCO2 are a good guide to the outcome of assisted ventilation in hypercapnic respiratory failure due to COPD (a pH of more than 7.35 is a better predictor of survival during the acute episode). Click here to go back to the pathway 14 Oxygen therapy oxygen should be prescribed to achieve target saturations of 94-98% for most acutely ill patients or 88-92% for those at risk of hypercapnic respiratory failure check blood gases after 30-60 minutes (or if there is clinical deterioration) even if the initial PaCO2 level was normal the target saturation should be written on the drug chart if the PaO2 is raised but PH is greater or equal to 7.5, patient has probably got long standing COPD, maintain target range of 88-92% saturation if the patient is hypercapnic (PaCO2 greater than 6KPA or 46mm of mercury) and acidotic (PH less than 7.35 or hydrogen ion concentration more than 45nmol/L), consider non invasive ventilation, especially if acidosis has persisted for more than 30 minutes despite appropriate therapy pH less than 7.35 - consider ventilatory support Click here to go back to the pathway 15 Bronchodilators increase frequency of bronchodilator use - consider giving via a nebuliser nebulised bronchodilators should be given on arrival and at 4-6 hourly intervals thereafter (more frequently if required) moderate exacerbations - give beta-agonist (salbutamol 2.5-5mg or terbutaline 5-10mg) or an anticholinergic drug (ipratropium bromide 0.25-0.5mg) if severe exacerbations/response to either treatment alone is poor, both beta agonist and anticholinergic drug may be administered oxygen can continue to be given by nasal prongs at 1-2L/min during nebulisation in order to prevent the fall in oxygen saturation that sometimes occurs with the use of nebulisers if patient is hypercapnic/acidotic, the nebuliser should be driven by compressed air, not oxygen (to avoid worsening hypercapnia) – oxygen therapy can be administered simultaneously by nasal cannulae if needed Date agreed: February 2011 Review Date: February 2013 Page 7 of 16 formal assessment after recovery from the acute episode is still required if the patient is not responding, intravenous (IV) methylxanthines by continuous infusion (aminophylline 0.5mg/kg per hour) should be considered (measure blood levels of theophylline daily) nebulised bronchodilators should be continued for 24-48 hours or until the patient is improving clinically – bronchodilators can then be given by metered-dose aerosol or dry powder inhaler Click here to go back to the pathway 16 Corticosteroid therapy use in conjunction with other therapies in all patients admitted to hospital use 7-14 day course of systemic corticosteroids (prednisolone 30mg/day or hydrocortisone if the oral route is not possible) if: o the patient is already on maintenance oral corticosteroids; or o there is a previously documented response to oral corticosteroids; or o the airflow obstruction fails to respond to an increase in bronchodilator dosage; or o this is the first presentation of airways obstruction discontinue after the acute episode, unless they have shown to be effective when the patient is clinically stable or there is a definite indication for long-term treatment assess need for long-term inhaled corticosteroids separately osteoporosis prophylaxis - consider if frequent corticosteroid courses are required withdrawal after chronic therapy (more than 7 days) must be gradual (i.e. tapered off over weeks or months) Click here to go back to the pathway 17 Antibiotic and other available treatments Antibiotic treatment in acute exacerbations of chronic obstructive pulmonary disease (COPD): use if: o increased sputum purulence and either increased breathlessness or increased sputum volume o consolidation on a chest radiograph o clinical signs of pneumonia initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline always take account of any guidance issued by their local microbiologist appropriateness of antibiotic treatment should be checked against laboratory culture and sensitivities when they become available Intravenous (IV) theophylline: use only: o after a trial of short-acting and long-acting bronchodilators o as an adjunct if there is inadequate response to nebulised bronchodilators dose of theophylline prescribed should be reduced at time of exacerbation if macrolide or fluoroquinolone antibiotics are prescribed be cautious of interactions with other drugs and potential toxicity if patient has been on oral theophylline: o particular caution is recommended in elderly patients due to: differences in pharmacokinetics increased likelihood of co-morbidities use of other medication monitor levels within 24 hours of starting treatment and subsequently as frequently as clinically indicated effectiveness of treatment should be assess by improvement in the following: o symptoms o activities of daily living o exercise capacity o lung function Date agreed: February 2011 Review Date: February 2013 Page 8 of 16 Respiratory stimulants: use doxapram only when non-invasive ventilation is unavailable/considered inappropriate Pulmonary emboli are more common than is usually recognised in severe COPD but the benefit of prophylactic anticoagulation treatment has not been evaluated. Click here to go back to the pathway 18 Progress satisfactory monitor by regular clinical assessment of their symptoms and observation of their functional capacity use pulse oximetry to monitor the recovery of patients with non-hypercapnic, non-acidotic respiratory failure use intermittent arterial blood gas measurements to monitor recovery of patients with respiratory failure who are hypercapnic or acidotic, until they are stable do not perform daily monitoring of peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) routinely Click here to go back to the pathway 19 Progress not satisfactory monitor by regular clinical assessment of their symptoms and observation of their functional capacity use pulse oximetry to monitor the recovery of patients with non-hypercapnic, non-acidotic respiratory failure use intermittent arterial blood gas measurements to monitor recovery of patients with respiratory failure who are hypercapnic or acidotic, until they are stable do not perform daily monitoring of peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) routinely Click here to go back to the pathway 20 Monitor progress Monitoring and management as the patient recovers: in addition to the routine hospital observations, the following should be considered: o forced expiratory volume in 1 second (FEV1) should be recorded before discharge from hospital o patients with low partial pressure of oxygen in arterial blood (PaO2) on admission should have arterial blood gas tensions checked on air before discharge o this gives a guide to the need for later formal re-assessment for long-term oxygen therapy (LTOT therapy) as the clinical condition improves (less dyspnoea, improved oxygen saturation of arterial blood [SaO2]) the nebulised bronchodilator can be changed to the patient's usual inhaler, ideally at least 24-48 hours before discharge antibiotics usually do not need to be continued for more than 7 days if oral corticosteroids have been used they can usually be stopped abruptly after 7 days, unless there are positive reasons for long-term usage Click here to go back to the pathway 21 Monitor progress Monitoring and management as the patient recovers: in addition to the routine hospital observations, the following should be considered: o forced expiratory volume in 1 second (FEV1) should be recorded before discharge from hospital Date agreed: February 2011 Review Date: February 2013 Page 9 of 16 patients with low partial pressure of oxygen in arterial blood (PaO2) on admission should have arterial blood gas tensions checked on air before discharge o this gives a guide to the need for later formal re-assessment for long-term oxygen therapy (LTOT) as the clinical condition improves (less dyspnoea, improved oxygen saturation of arterial blood [SaO2]) the nebulised bronchodilator can be changed to the patient's usual inhaler, ideally at least 24-48 hours before discharge antibiotics usually do not need to be continued for more than 7 days if oral corticosteroids have been used they can usually be stopped abruptly after 7 days unless there are positive reasons for long-term usage consider hospital-at-home or assisted-discharge scheme o Click here to go back to the pathway 22 Consider palliative care Palliative care: opioids can be used for the palliation of breathlessness in patients with end-stage chronic obstructive pulmonary disease (COPD) unresponsive to other medical therapy also use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen when appropriate for the palliation of breathlessness in patients with end-stage COPD unresponsive to other medical therapy involve patients with end-stage COPD, their family, and carers with multidisciplinary palliative care teams and services, including admission to hospices Click here to go back to the pathway 23 Planning for discharge aim to improve the ability of patients to cope within their limitations at home and to reduce the need for future admissions make adequate arrangements for follow-up and home care (such as visiting nurse, oxygen delivery, referral for other support) the patient, family and physician should be confident that he or she can manage successfully Arrange a multidisciplinary assessment and consider: medical factors: o a review of all medication (including non-respiratory treatments) o establish on optimal therapy before discharge o review inhaler technique o measure spirometry o ensure the patient knows how and when to take his or her medication o for the few patients discharged on a nebuliser, the specific reasons for continuing nebulised treatment should be recorded o patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge social factors and ability to manage at home: o assessment of mobilisation and giving preliminary instruction in rehabilitation o assessment of home needs such as shopping, cleaning, obtaining medication, and provision of equipment to assist in daily living o financial assessment – patients with chronic obstructive pulmonary disease (COPD) may be eligible for financial help from a number of different benefits Click here to go back to the pathway 24 Pulmonary rehabilitation Pulmonary rehabilitation: should be available to all appropriate patients with chronic obstructive pulmonary disease (COPD), including those recently hospitalised for an acute exacerbation Date agreed: February 2011 Review Date: February 2013 Page 10 of 16 programme should be: o multidisciplinary programme of care o individually tailored to optimise the individual's physical and social performance and autonomy o be held at times that suit patients, and in buildings that are easy for the patient to get to in practice, usually offered to those who consider themselves functionally disabled by COPD (usually MRC grade 3 and above) not suitable for those: o unable to walk o with unstable angina o who have had a recent myocardial infarction should include: o physical training o disease education o nutritional intervention o psychological intervention o behavioural intervention patient should be made aware of the benefits of rehabilitation and the commitment required to gain these benefits MRC dyspnoea scale. Grade Degree of breathlessness related to activities 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100m or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing Local Information Due to limited access to pulmonary rehab services in the ABMU Health Community this service is only available by consultant referral. Any patients assessed as meeting the criteria in primary care should be referred to a secondary care specialist, requesting assessment for pulmonary rehab. Click here to go back to the pathway 25 Planning for discharge aim to improve the ability of patients to cope within their limitations at home and to reduce the need for future admissions make adequate arrangements for follow-up and home care (such as visiting nurse, oxygen delivery, referral for other support) the patient, family and physician should be confident that he or she can manage successfully Arrange a multidisciplinary assessment and consider: medical factors: o a review of all medication (including non-respiratory treatments) o establish on optimal therapy before discharge o review inhaler technique o measure spirometry o ensure the patient knows how and when to take his or her medication o for the few patients discharged on a nebuliser, the specific reasons for continuing nebulised treatment should be recorded o patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge social factors and ability to manage at home: o assessment of mobilisation and giving preliminary instruction in rehabilitation Date agreed: February 2011 Review Date: February 2013 Page 11 of 16 o o assessment of home needs such as shopping, cleaning, obtaining medication, and provision of equipment to assist in daily living financial assessment – patients with chronic obstructive pulmonary disease (COPD) may be eligible for financial help from a number of different benefits Click here to go back to the pathway 26 Informing effective discharge Maintaining high quality medical records is a fundamental and crucial component of good clinical practice. Omissions, errors, and illegible records undermine the quality and safety of clinical care and expose doctors and health care providers units to increased risk of clinical incidents, complaints, and litigation. [Bridgelal Ram] The following is designed to serve as a concise reminder for clinicians to ensure patient discharge notes are accurate, and to facilitate effective discharge. HIU Discharge Summary The following should be recorded and updated throughout the patient's hospital stay: GP details: record the details of the patient’s usual GP. Patient details: record the patient details, including NHS number and home address. Admission details: record the method of admission (e.g. emergency, elective, transfer, maternity), hospital site, responsible Trust, and date of admission. Discharge details: record date of discharge, method (e.g. on clinical advice, self-discharge), discharge destination, discharging consultant, and discharging specialty/department. Clinical information: record diagnosis at discharge, operations and procedures performed during admission, relevant legal information (e.g. Mental Capacity Act 2005), allergies, risks and warnings, clinical narrative, outstanding investigations, measures of physical ability and cognitive function, medication changes, and discharge medications. Advice, recommendations, and future plan: record actions required by hospital and/or GP, actions requested/planned/agreed with community, and specialist services. Patient’s concerns, expectations, and wishes Information given to patient and/or authorised representative Results awaited Person completing the summary: record doctor’s name and GMC number, grade, signature, date of completion, and bleep number. High quality discharge notes ensure proper documentation of patient care and treatment plans, minimise variability and errors during discharge, and assure continuity of care and communication between care providers. The Health Informatics Unit of the Royal College of Physicians (RCP), London, UK, working on behalf of the Academy of Medical Royal Colleges (AMRC) developed a discharge medical record keeping standard. [RCP 1, RCP 2] The standard was approved by the AMRC in 2008. The standard is designed to encourage formal discharge planning at the point of admission for all in-patients and effective transfer of care tailored to the patient’s health needs and local care provider context. Click here to go back to the pathway 27 Informing effective discharge Maintaining high quality medical records is a fundamental and crucial component of good clinical practice. Omissions, errors, and illegible records undermine the quality and safety of clinical care and expose doctors and health care providers units to increased risk of clinical incidents, complaints, and litigation. [Bridgelal Ram] The following is designed to serve as a concise reminder for clinicians to ensure patient discharge notes are accurate, and to facilitate effective discharge. HIU Discharge Summary The following should be recorded and updated throughout the patient's hospital stay: GP details: record the details of the patient’s usual GP. Patient details: record the patient details, including NHS number and home address. Date agreed: February 2011 Review Date: February 2013 Page 12 of 16 Admission details: record the method of admission (e.g. emergency, elective, transfer, maternity), hospital site, responsible Trust, and date of admission. Discharge details: record date of discharge, method (e.g. on clinical advice, self-discharge), discharge destination, discharging consultant, and discharging specialty/department. Clinical information: record diagnosis at discharge, operations and procedures performed during admission, relevant legal information (e.g. Mental Capacity Act 2005), allergies, risks and warnings, clinical narrative, outstanding investigations, measures of physical ability and cognitive function, medication changes, and discharge medications. Advice, recommendations, and future plan: record actions required by hospital and/or GP, actions requested/planned/agreed with community, and specialist services. Patient’s concerns, expectations, and wishes Information given to patient and/or authorised representative Results awaited Person completing the summary: record doctor’s name and GMC number, grade, signature, date of completion, and bleep number. High quality discharge notes ensure proper documentation of patient care and treatment plans, minimise variability and errors during discharge, and assure continuity of care and communication between care providers. The Health Informatics Unit of the Royal College of Physicians (RCP), London, UK, working on behalf of the Academy of Medical Royal Colleges (AMRC) developed a discharge medical record keeping standard. [RCP 1, RCP 2] The standard was approved by the AMRC in 2008. The standard is designed to encourage formal discharge planning at the point of admission for all in-patients and effective transfer of care tailored to the patient’s health needs and local care provider context. Click here to go back to the pathway 28 Follow-up care Follow-up in hospital or by general practitioner: arrangements are required for all patients 4-6 weeks after discharge assessment at the first follow-up to include: o the patient's ability to cope o measurement of forced expiratory volume in 1 second (FEV1) o re-assessment of inhaler technique and of the patient's understanding of recommended treatment regime o in severe chronic obstructive pulmonary disease (COPD) the need for long-term oxygen therapy (LTOT) and/or home nebuliser usage o advice on smoking cessation as necessary Follow-up thereafter is as for stable COPD: follow-up of patients with mild or moderate COPD will usually take place in primary care and should include: o highlighting in the case record the diagnosis of COPD and the values of spirometric tests performed at diagnosis o supervision of smoking cessation o documenting the effects of each drug treatment as it is tried o recording changes in spirometric parameters measured opportunistically at intervals Severe disease: patients with severe COPD are likely to have frequent exacerbations leading to hospital admissions they often have complex problems with co-morbidities, may be on high levels of treatment, and need monitoring for long-term oxygen therapy (LTOT) shared care between the hospital and GP is the usual pattern although there are no data to show how care should be provided to achieve the best combination of clinical and cost effectiveness routine isolated peak expiratory flow (PEF) measurements once a patient is stable are of little value because of the discordance between PEF and FEV1 Date agreed: February 2011 Review Date: February 2013 Page 13 of 16 NB: A loss of 500mL over 5 years will identify those patients with rapidly progressing disease who may need specialist referral and investigation. Click here to go back to the pathway 29 Follow-up care Follow-up in hospital or by general practitioner: arrangements are required for all patients 4-6 weeks after discharge assessment at the first follow-up to include: o the patient's ability to cope o measurement of forced expiratory volume in 1 second (FEV1) o re-assessment of inhaler technique and of the patient's understanding of recommended treatment regime o in severe chronic obstructive pulmonary disease (COPD) chronic obstructive pulmonary disease (COPD) the need for longterm oxygen therapy and/or home nebuliser usage o advice on smoking cessation as necessary Follow-up thereafter is as for stable COPD: follow-up of patients with mild or moderate COPD will usually take place in primary care and should include: highlighting in the case record the diagnosis of COPD and the values of spirometric tests performed at diagnosis supervision of smoking cessation documenting the effects of each drug treatment as it is tried recording changes in spirometric parameters measured opportunistically at intervals Severe disease: patients with severe COPD are likely to have frequent exacerbations leading to hospital admissions they often have complex problems with co-morbidities, may be on high levels of treatment, and need monitoring for long-term oxygen therapy (LTOT) shared care between the hospital and GP is the usual pattern although there are no data to show how care should be provided to achieve the best combination of clinical and cost effectiveness routine isolated peak expiratory flow (PEF) measurements once a patient is stable are of little value because of the discordance between PEF and FEV1 NB: A loss of 500mL over 5 years will identify those patients with rapidly progressing disease who may need specialist referral and investigation. Click here to go back to the pathway 31 Long-term follow-up All patients with chronic obstructive pulmonary disease (COPD) require the following at follow-up: Follow-up in hospital or by general practitioner - arrangements are required for all patients 46 weeks after discharge highlight diagnosis in notes and computer database record results of spirometric tests at diagnosis (absolute and percentage of predicted) document the effects of each drug treatment as it is tried record opportunistic measurements of spirometric parameters (loss of 500mL over 5 years will identify those with rapidly progressing disease – may need specialist referral and investigation) assessment of disease severity should take into account: o degree of airflow obstruction o degree of disability o frequency of exacerbations o prognostic factors such as: Date agreed: February 2011 Review Date: February 2013 Page 14 of 16 o o forced expiratory volume in 1 second (FEV1) transfer factor for carbon monoxide (TLCO) breathlessness (using the MRC dyspnoea scale) health status exercise capacity body mass index (BMI) partial pressure of oxygen in arterial blood (PaO2) cor pulmonale measurements required: FEV1 and forced vital capacity (FVC) BMI MRC dyspnoea score clinical assessment to include: smoking status and desire to quit adequacy of symptom control: breathlessness exercise tolerance estimated exacerbation frequency presence of complications effects of each drug treatment inhaler technique need for referral to specialist and therapy services need for pulmonary rehabilitation Follow-up in primary care of mild COPD (FEV1 50-80%) and moderate COPD (FEV1 30-49%) is required at least twice per year and clinical assessment needs to evaluate presence of complications. Follow-up in primary care of severe COPD (FEV1 less than 30%) as above and: frequency - at least twice per year clinical assessment: o presence of cor pulmonale o need for long-term oxygen therapy (LTOT) o patient's nutritional state o presence of depression o need for social services and occupational therapy input o measurement of oxygen saturation of arterial blood (SaO2) regular hospital review not normally needed in stable severe COPD locally agreed mechanisms should allow rapid hospital assessment when needed likely to have frequent exacerbations leading to hospital admissions may need monitoring for LTOT shared care between the hospital and GP is the usual pattern Click here to go back to the pathway 35 Long-term follow-up All patients with chronic obstructive pulmonary disease (COPD) require the following at follow-up: Follow-up in hospital or by general practitioner - arrangements are required for all patients 46 weeks after discharge highlight diagnosis in notes and computer database record results of spirometric tests at diagnosis (absolute and percentage of predicted) document the effects of each drug treatment as it is tried record opportunistic measurements of spirometric parameters (loss of 500mL over 5 years will identify those with rapidly progressing disease – may need specialist referral and investigation) assessment of disease severity should take into account: o degree of airflow obstruction o degree of disability o frequency of exacerbations o prognostic factors such as: Date agreed: February 2011 Review Date: February 2013 Page 15 of 16 o o forced expiratory volume in 1 second (FEV1) transfer factor for carbon monoxide (TLCO) breathlessness (using the MRC dyspnoea scale) health status exercise capacity body mass index (BMI) partial pressure of oxygen in arterial blood (PaO2) cor pulmonale measurements required: FEV1 and forced vital capacity (FVC) body mass index (BMI) MRC dyspnoea score clinical assessment to include: smoking status and desire to quit adequacy of symptom control: breathlessness exercise tolerance estimated exacerbation frequency presence of complications effects of each drug treatment inhaler technique need for referral to specialist and therapy services need for pulmonary rehabilitation Follow-up in primary care of mild COPD (FEV1 50-80%) and moderate COPD (FEV1 30-49%) is required at least twice per year and clinical assessment needs to evaluate presence of complications Follow-up in primary care of severe COPD (FEV1 less than 30%) as above and: frequency - at least twice per year clinical assessment: o presence of cor pulmonale o need for long-term oxygen therapy (LTOT) o patient's nutritional state o presence of depression o need for social services and occupational therapy input o measurement of oxygen saturation of arterial blood (SaO2 regular hospital review not normally needed in stable severe COPD locally agreed mechanisms should allow rapid hospital assessment when needed likely to have frequent exacerbations leading to hospital admissions may need monitoring for LTOT shared care between the hospital and GP is the usual pattern Click here to go back to the pathway References Please click on the below icon for the list of references COPD Pathways References.doc Date agreed: February 2011 Review Date: February 2013 Page 16 of 16